Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a non-healing diabetic foot ulcer of [Duration] duration. Associated symptoms include [purulent discharge/foul odor/increasing pain/erythema/edema]. Patient reports [fever/chills/malaise]. History of poorly controlled DM type 2, peripheral neuropathy, and PAD. Current wound care regimen: [Regimen]. No prior surgical intervention for this site.
Clinical Examination Findings
Vitals: [Temp/HR/BP]. Local Exam: Ulcer located at [Site: e.g., plantar aspect of 1st metatarsal head]. Dimensions: [Length x Width x Depth] cm. Wound bed: [Granulation/Slough/Necrotic]. Discharge: [Serous/Purulent/Bloody]. Surrounding tissue: [Erythema/Induration/Crepitus]. Neurovascular: [Dorsalis pedis/Posterior tibial pulses: Present/Absent/Diminished]. Monofilament test: [Positive/Negative]. Probe-to-bone test: [Positive/Negative].
Treatment Protocol
Plan: 1. Surgical debridement of necrotic tissue and infected bone as indicated. 2. Cultures (deep tissue/bone) sent for C&S. 3. Empirical IV antibiotic therapy initiated: [Antibiotic regimen]. 4. Offloading measures: [Total contact cast/Offloading shoe]. 5. Glycemic control optimization via insulin sliding scale. 6. Vascular surgery consultation for revascularization assessment.